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1 <br /> e.. SAN JOAQUIN COUNTY <br /> 4_� e i <br /> 2' 'y ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> j <br /> SITE MITIGATION <br /> 1 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV A <br /> i-.,. Telephone:(209)468-3454 Fac:(209)468.3433 Web:www.siclov.oralehd <br /> WELL &BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or insiall the work described. This application Is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and ttwh`e Standards of the San Joaquin County Environmental Health Department. <br /> Site Location �yx, USC* IZ. Cross Street 1�luc(.�2SS �11 City cSVr.6L4O`4\ Zip AFN0+\\2)O\S <br /> Property y}CS\ A�('CCG\f7 <br /> owner vc �v\w:\et Address Kalmsa% Z\� city zip94S-4 Phone �oT�55?-t1Ra <br /> Adress �Z ,OCirccity RnVwPhoneC \ ) oS ' \\ <br /> C-57 Contractor CBCQ� a � <br /> Consultanf/Sub Cnlr�ZL Ad (Wob2 f�wor.S 7c \� Cary fQ�\cA�.T.v�a� Lic Phone \1y1c0 <br /> Billable Parry Address J&PU& (�"KA ibc • V:91 City P\enSC+'�kbA Zip Q�iS^c7P� Phone(nZS lUW-53b0 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: @ <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS j <br /> ❑WELL IDs <br /> OTHER IDs ! <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING O HOLLOW STEM OAA OF BOREHOLE O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _CI EXTRACTION:Vapor/Water O HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER <br /> _O SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS O HOSE O PIPE <br /> r` _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> I _O INJECTION re Ar Soaraa Ozcn 0HAND AUGER GROUT SPECIFICATIONS <br /> j _O OTHER: El OTHER: APPROX BORING DEPTH ❑8OLTED TRAFFICBOX OR D STOVE PIPE <br /> II CONDUCTOR CASING O No O Yes:Casing Ole: Casing Depth:_ Boring Dia:_ <br /> I. COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHEDKALL THAT APPLY) <br /> #OF WELI(S)TO BE DESTROYED .I OVER-BORE DIAMETER OF Zo INCHES T9 DEPTH OF 3 FT <br /> WELL IDS: �lW`(D t 0A.W � �i K PRESSURE GROUT TO DEPTHS Z,,�S FTBELOWSURFACE <br /> GROUT SPECIFICATIONS - El EXPLOSIVES FROM TO FTSELOWSURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE ' J'MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that.the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all plica�9e Calitont Laws. <br /> Signed �;� \ '� Tige/Company <br /> Pdnt Name 1`a pa�pr:De� F\Cly-f v�Q-tf' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESSS 19 7 W Ctl r- L e <br /> WORK PLAN DATED Al2rd 2: <br /> APPLICATION ACCEPTED BYVI C'I-A ria l72�/'Qtfi7P.Li DATE I l S <br /> GROUT INSPECTION BY .4i FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: — <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE - SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3 2 $125X Z -.SO. 00 /230 9 L 20 z SR# 0065 S <br /> ArRO# <br /> 3' 3 00 g S cD 3soo) 2 <br /> L 2 S 00 ssoo <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT 0OC <br />